Dounel Jonathan, Lamorte Carolyn, Patton Heather, Perumalswami Ponni, McCurdy Heather, Kim Nicole J, Beste Lauren A, Scott Dawn, Casey Jessimarie, Spoutz Patrick, Chia Linda, Yao Yiwen, Lowy Elliott, Gibson Sandra, Morgan Timothy R, Rogal Shari S
VA San Diego Healthcare System, San Diego, CA, USA.
University of California San Diego, La Jolla, CA, USA.
BMC Health Serv Res. 2025 Jan 29;25(1):168. doi: 10.1186/s12913-025-12216-8.
Because cirrhosis is often unrecognized, we aimed to develop a stepwise screening algorithm for cirrhosis in the Veterans Health Administration (VHA) and assess this approach's feasibility and acceptability.
VHA hepatology clinicians ("champions") were invited to participate in a pilot program from June 2020 to October 2022. The VHA Corporate Data Warehouse was queried to identify Veterans with possible undiagnosed cirrhosis using Fibrosis-4 (FIB-4) ≥ 3.25 and at least one risk factor for liver disease (e.g., obesity), and generate an age-stratified sample. Champions at four sites reviewed charts to confirm eligibility and contacted Veterans to offer further evaluation with elastography. Feasibility was defined as protocol implementation with completion of at least one elastography test and acceptability was defined based on Veteran- and clinician-reported surveys. Participation in the program, patient outcomes, adaptations to the protocol, and implementation barriers were also assessed.
Four sites were able to implement the screening protocol. Adaptations included type of outreach (primary care vs. hepatology, phone vs. mail) and type of elastography used. One site chose to refer patients with clear evidence of cirrhosis directly to hepatology (n = 12) rather than to elastography. Key implementation barriers included staffing, primary care provider (PCP) comfort with interpreting and communicating results, and appointment availability during the COVID-19 pandemic. Of 488 patients whose charts were reviewed, 230 were excluded from outreach based on predefined criteria (e.g., advanced cancer, prior or current referral to hepatology). Champions and PCPs attempted to contact 165 of 246 Veterans who were deemed eligible for evaluation with elastography. Among 53 Veterans who completed elastography, 22 (42%) had findings consistent with significant fibrosis and were referred to hepatology. Clinicians and Veterans reported high acceptability of the program on surveys (80% of Veterans who completed survey).
This pilot demonstrated the feasibility, acceptability, and challenges of a multisite approach to cirrhosis screening.
由于肝硬化常常未被识别，我们旨在开发一种针对退伍军人健康管理局（VHA）肝硬化的逐步筛查算法，并评估该方法的可行性和可接受性。
邀请VHA肝病临床医生（“倡导者”）参加2020年6月至2022年10月的试点项目。查询VHA企业数据仓库，以识别使用纤维化-4（FIB-4）≥3.25且至少有一个肝病风险因素（如肥胖）的可能未被诊断出肝硬化的退伍军人，并生成按年龄分层的样本。四个地点的倡导者审查病历以确认资格，并联系退伍军人提供弹性成像进一步评估。可行性定义为实施方案并完成至少一次弹性成像检查，可接受性根据退伍军人和临床医生报告的调查来定义。还评估了参与该项目情况、患者结局、对方案的调整以及实施障碍。
四个地点能够实施筛查方案。调整内容包括外展类型（初级保健与肝病科、电话与邮件）以及所使用的弹性成像类型。一个地点选择将有明确肝硬化证据的患者直接转诊至肝病科（n = 12），而非进行弹性成像检查。关键实施障碍包括人员配备、初级保健提供者（PCP）对解读和传达结果的信心，以及在新冠疫情期间的预约可用性。在488名病历被审查的患者中，根据预定义标准（如晚期癌症、既往或当前转诊至肝病科），有230名被排除在外展范围之外。倡导者和PCP试图联系246名被认为有资格接受弹性成像评估的退伍军人中的165名。在53名完成弹性成像检查的退伍军人中，22名（42%）的检查结果与显著纤维化一致，并被转诊至肝病科。临床医生和退伍军人在调查中报告该项目具有较高的可接受性（完成调查的退伍军人中有80%）。
该试点证明了多地点肝硬化筛查方法的可行性、可接受性及挑战。
